Important questions from a future applicant

[Apply Pressure]

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Hi all.. I'm currently a third year student and had some questions about applying to residency.

I'm a weak applicant for a competitive specialty I REALLY want to pursue. Since I want to be realistic about matching, I have also considered applying for internal medicine (and going on to subspecialize) as a second option. Luckily, I'm quite interested in a few of the fellowships offered after IM and wouldn't mind pursuing them if I had to.

My questions revolve around planning 4th year and applying properly so that I have the greatest success given my circumstance.

1) The specialty I'm applying for will allow an IM prelim year. Is it more beneficial to:

a) apply only in the competitive specialty, risk not matching, and default into the prelim year? In this circumstance I would either reapply into the competitive specialty or try to get my foot in the door for a categorical spot during PGY1

OR

b) apply to both the competitive specialty and IM together (as an MS IV) and see what happens.

2) In the event I take option "a)" above, how difficult is it to get a categorical spot in IM for PGY2 year? Also, does it have to be done at the same hospital, or can I apply to a different place for the categorical training?

3) How do PGY1 reapplicants to competitive specialties fare in the match?

4) Should I plan away rotations for 4th year in the competitive specialty at the best hospitals possible, or should I try to rotate somewhere where I'm likely to match/where they'll give me a shot?

5) If I apply as option "b)" above (apply to 2 specialties), would it be a better idea to split my away rotations so that I rotate in both specialties at different institutions, or am I better off only rotating in the competitive specialty to maximize my chances?


Thanks for helping me with some of these complicated questions. 👍

 

[Law2Doc]

Hi all.. I'm currently a third year student and had some questions about applying to residency.

I'm a weak applicant for a competitive specialty I REALLY want to pursue. Since I want to be realistic about matching, I have also considered applying for internal medicine (and going on to subspecialize) as a second option. Luckily, I'm quite interested in a few of the fellowships offered after IM and wouldn't mind pursuing them if I had to.

My questions revolve around planning 4th year and applying properly so that I have the greatest success given my circumstance.

1) The specialty I'm applying for will allow an IM prelim year. Is it more beneficial to:

a) apply only in the competitive specialty, risk not matching, and default into the prelim year? In this circumstance I would either reapply into the competitive specialty or try to get my foot in the door for a categorical spot during PGY1

OR

b) apply to both the competitive specialty and IM together (as an MS IV) and see what happens.

2) In the event I take option "a)" above, how difficult is it to get a categorical spot in IM for PGY2 year? Also, does it have to be done at the same hospital, or can I apply to a different place for the categorical training?

3) How do PGY1 reapplicants to competitive specialties fare in the match?

4) Should I plan away rotations for 4th year in the competitive specialty at the best hospitals possible, or should I try to rotate somewhere where I'm likely to match/where they'll give me a shot?

5) If I apply as option "b)" above (apply to 2 specialties), would it be a better idea to split my away rotations so that I rotate in both specialties at different institutions, or am I better off only rotating in the competitive specialty to maximize my chances?


Thanks for helping me with some of these complicated questions. 👍

You probably shouldn't take the position that you will look solely at a competitive path and have as your fallback a prelim year which you will hope to convert to a categorical path. Better to apply to both the competitive path (plus prelim/TY) and to categorical medicine paths and then rank them in that order, so that if you don't get the competitive path, you perhaps are all set with medicine as your second choice. You will have a much harder time trying to interview while an intern and try to line up a medicine path post graduation as compared to lining it up as a fallback now. As for away rotations, it probably pays to be realistic, rather than simply the "best" hospital in a field you already question whether you are competitive for. Better to have an audition at a realistic match option than to spend a month at a place you aren't going to get anyhow. I would focus the away rotations on the more competitive field (you can get by without an away rotation in medicine unless you have your heart set on a specific location).

 

[Samoa]

This is out of order, but here are my thoughts on your situation. I am currently a reapplicant in a competitive field (who was a very competitive applicant the first time around and didn't match for reasons that aren't relevant to your situation).

1. Your best chance of matching in a competitive specialty (or any field, really) is as a 4th year med student. If you are a below average applicant for that field, you will be at a much more severe disadvantage in subsequent years, no matter what you do to improve your application. So apply the first time as broadly as you can possibly afford.

2. PDs can and do use your approach to the match as an indicator of your ability to make good judgments. If you are not a competitive applicant, it can reflect poorly on you to apply as if you are (i.e. only in the competitive specialty with only prelims as a backup). It appears far more mature to apply in the competitive field AND a categorical backup in a less competitive field, as well as the prelims. Even if you have no intention of ever ranking the categorical backup. It shows that you've realistically appraised your situation and know that your chances aren't great, and that this is the best chance you have.

If you end up with a lot of interviews in the competitive field, you can always cancel your backup interviews, and rank only the prelims as a backup. Or go on one or two categorical backups, just in case--which is what I would do in your shoes, since if you fall through all the way through your desired field's programs, it is VERY likely you will not match in that field the second time around, or even get interviews.

(If you doubt, take a look at "Charting Outcomes in the Match." Even applicants who were competitive as 4th year med students have a significantly harder time in subsequent matches.)

3. Away rotations may help you in your competitive field (or not, hard to say without knowing what field), but very likely they won't help you in medicine. So if the field is one where aways are expected, do them both in that field. Do one of them at a place where you can get a letter from a big name in the field (kind of as a stamp of approval that you're capable despite your grades/scores). Do the other someplace where you might have a chance of matching.

4. It is easier to find a PGY-2 in medicine than it is to reapply and match in a competitive specialty. So if you just can't bring yourself to rank the categorical option, you still have a way out. BUT, likely you would match at a better program as 4th year med student than you could find a PGY-2 spot at, or match into categorically from a prelim position once you're out of school.

 

[Doctor Bob]

If you are a below average applicant for that field, you will be at a much more severe disadvantage in subsequent years, no matter what you do to improve your application.

(If you doubt, take a look at "Charting Outcomes in the Match." Even applicants who were competitive as 4th year med students have a significantly harder time in subsequent matches.)

In the civilian world perhaps... but quite the opposite in the military.
(But Dr. Bob, nobody cares about that.
I know, I know. But that's the experience I can speak from and maybe there are some similarities that can help other people out.

Turning an application around after you graduate is not an easy thing to do (as evidenced by the COitM thing mentioned above). Some of the things you can do tend to be longer term than what you can accomplish in the first half of a prelim year (which is all the time you'd have if your plan is to reenter the match as soon as possible).

One thing you can do is take Step III. But this is a risk. A big risk. If you do really well (ie: a lot better than I and II) then it shows a definite improvement. But if you do the same as the other two parts, or (worst case scenario) you fail it then you've just shot yourself in the foot in a way that you probably can't come back from.

Research is an option, but again you really ought to do that for a year or two to become helpful.

So what am I saying?
Not much that's helpful
Thank you inner voice. Doing a prelim year may not strategically help you even if the option to match in advanced standing is out there only because you won't be able to turn it around in the short amount of time.

Go all out for the competitive specialty during 4th year, rank categorical programs in that specialty highly, rank IM programs below it, but whatever you do don't let the competitive specialty programs find out that you're willing to do IM as a back up. At least in the military that counts against you during selection time as it shows "lack of commitment to the specialty".

 

[Samoa]

I agree with you, in the case of a competitive applicant for a competitive field. Applying in a backup field can be viewed as lack of confidence--which would be viewed as a negative.

But for an applicant who is a longshot to match in a competitive field, most PDs would view NOT having a backup as an indication of poor judgment, moreso than strong commitment.

However, I can see how the backup field might think the applicant lacks commitment.

Military applicants aren't included in the Outcomes document, so if the OP is military, s/he would get better info in the military forum.

 

[Apply Pressure]

Hey guys thanks for the replies. I never seriously considered applying to two specialties at once but its something I'll think about now.

I realize I'm attempting to find out lots of information in one thread but I would appreciate answers to a few follow up questions if any of you are game.

By the way, I'm not military.

1) Who gets to know if you've applied to multiple specialties? Can PDs see your application designations/rank list?
2) Do you get two sets of letters or should you/can you mix and match?
3) Do you need to write 2 separate personal statements and can you assign which program gets which?
4) Is it possible to interview at the same place for both a categorical and prelim IM spot?
5) Along the same lines, is it possible to interview at the same place for a slot in the competitive residency and in IM?
6) How do you approach faculty during 4th year and tell them you'll be applying to two specialties without them thinking less of you as an applicant?

😕

 

[Samoa]

1) Who gets to know if you've applied to multiple specialties? Can PDs see your application designations/rank list?

No one knows unless you tell them.

2) Do you get two sets of letters or should you/can you mix and match?

You can do either. Just be very clear with the LOR writers about the field(s) you'll be using their letter for, so that they can write a general or specific letter accordingly.

3) Do you need to write 2 separate personal statements and can you assign which program gets which?

yes, to both

4) Is it possible to interview at the same place for both a categorical and prelim IM spot?

Yes, interviewing for categorical and prelim at the same institution is OK.

5) Along the same lines, is it possible to interview at the same place for a slot in the competitive residency and in IM?

It's possible, but very poor form, and counterproductive if the departments talk--which they will at some point if your competitive field needs an IM prelim. So apply broadly in the more competitive field, and target your application in the less competitive field to programs you're either not applying to in the other field, or have already been rejected from.

6) How do you approach faculty during 4th year and tell them you'll be applying to two specialties without them thinking less of you as an applicant?

Ask people to write letters immediately after your 3rd year IM rotation, and to keep them on file for 4th year, because you are considering IM as a specialty. Ask people in the more competitive specialty to write letters after the specialty rotation, and keep them on file as well for when you apply. Also ask anyone for a letter whom you think would write a strong one on your behalf, whose LOR might be applicable to either field, and ask them to make it a general letter.

When the time comes, have them all uploaded and assign as appropriate. Have the Dean's office staff verify that the letters you're using in both fields aren't specialty-specific.

This way you sidestep the issue entirely, since no one expects you to be entirely sure what you're applying for until the beginning of 4th year. But if you have to ask for a letter after this point, I think people appreciate honesty. Maybe not brutal honesty, but at least the general aura of openness about what you're doing.

 

[dragonfly99]

First, I'd suggest talking with your school's academic advising office to guesstimate your chances to match in the very competitive specialty. If they are truly awful, it might be better to just bail at this point and concentration on IM. If it's derm, for example, and you don't have any research and aren't in the top 1/3 of your class, I just don't see how you are going to get in. If it's something like radiology, you might potentially have a chance if you have OK USMLE scores and nothing "bad" on your dean's list (like failed classes, or personality conflicts).

Definitely do not do away rotations in a competitive specialty at a place where you don't have much chance of matching...that is a waste of time. Pick places where you might have some chance.

I don't think you need to do away rotations for IM...a lot of people don't. Regardless, if you're a decent US grad, you'll match somewhere OK as long as you throw out enough applications.

Yes, you need separate personal statements for each specialty. You mostly need separate LORs too...or at least make sure the derm ones don't say you want to do IM, etc.

I would not tell the categorical IM programs that you are also applying for rads or some other specialty...it will likely make them want you less b/c they'll feel you are not committed to the field. You might have to tell the truth @ your home institution, though. Honestly, my med school sometimes let people into IM knowing that the people wanted to bail and do something like derm or radiology later...BUT they needed 50 interns/year and had a vested interest in having people from our school (people who they knew were familiar with the hospital and mostly good students).

If you really want to go for broke, you could have prelim IM as your backup, and plan to do a research year after that in your chosen field...but I would check with faculty at your home institution, in your field of choice, to see if they have any input about your chances to get into your chosen field even with
-IM prelim year completed and with good evaluations, and
-1 research year

Doing an entire IM residency and then reapplying to your field of interest (during your PGY2 or 3 year) is always a possibility too. There was a guy in my medicine residency who went all the way through and then did radiology (@ another residency out of state). I don't know if IM was his original choice and he got burned out/changed his mind, or if IM was a backup from the start. I also don't know if he did anything to strength his application for rads (like research, etc.) while he was a medicine resident...I don't see how it would have been possible @my residency, as we didn't have much research time, but perhaps he found a way. Most people wouldn't do this (2 residencies) because they get sick of being a resident, or they are too in debt and end up wanting the IM attending salary to pay their student loans.

 

[Samoa]

Definitely do not do away rotations in a competitive specialty at a place where you don't have much chance of matching...that is a waste of time. Pick places where you might have some chance.

This really depends on the field. In a surgical field, the name on your letter is as important as the content, unlike in medicine where the content is far more important. So in a surgical field, it's a smart strategy to spend one away at a place where you might have a fairly low chance of matching, but can get a good letter from a well-known chairman.

If the OP isn't going into surgery, your strategy is better, though.

 

[Law2Doc]

This really depends on the field. In a surgical field, the name on your letter is as important as the content, unlike in medicine where the content is far more important. So in a surgical field, it's a smart strategy to spend one away at a place where you might have a fairly low chance of matching, but can get a good letter from a well-known chairman.

If the OP isn't going into surgery, your strategy is better, though.

While I think the "who you know" notion in your post is true for surgical (and some non-surgical) paths, I have to believe that a program where you spent a month auditioning and actually know all the players is going to be more helpful than a big name person's letter. Most programs don't get very good look at applicants in the interview process. When they get a better look at someone through an away rotation, and actually like them, that has to help. And a PD's own perception of an applicant will usually outweigh some other program's perception. So I'd say if you do an away at a program you have a shot at, and they like you, the odds of them ranking you highly are maximized. A letter from another program's bigwig probably helps a bit at programs you don't get to audition at, but I think it's probably lower yield. But only a PD can tell us this for sure.

 

[Samoa]

While I think the "who you know" notion in your post is true for surgical (and some non-surgical) paths, I have to believe that a program where you spent a month auditioning and actually know all the players is going to be more helpful than a big name person's letter. Most programs don't get very good look at applicants in the interview process. When they get a better look at someone through an away rotation, and actually like them, that has to help. And a PD's own perception of an applicant will usually outweigh some other program's perception. So I'd say if you do an away at a program you have a shot at, and they like you, the odds of them ranking you highly are maximized. A letter from another program's bigwig probably helps a bit at programs you don't get to audition at, but I think it's probably lower yield. But only a PD can tell us this for sure.

Obviously you should do one such rotation, and yes, that program will be your best chance of matching. But according to the NRMP's program director survey, who writes your letter is very important in surgical fields (i.e. the PDs have told us). Much more than in medicine. So for a surgical field applicant, it's a better use of your second rotation to get a letter from someone who's well-known and respected in the field, because that will help your application everywhere--not just where you've rotated.

 

[Law2Doc]

Obviously you should do one such rotation, and yes, that program will be your best chance of matching. ...

I still think if one such rotation is your best chance of matching, two would give you your second best chance of matching. So I guess it depends a lot on how far down the list you think you might have to go. I'd rather have two PD's who were impressed with me than 20 who were impressed with the letter I got. I still think that gives you better odds, but is highly dependent on how well you are able to impress. But I can see the merits in the strategy you describe as well. And certainly for an applicant who isn't certain to audition well, your strategy is higher yield.

 

[Samoa]

Are you going into surgery?

 

[PeepshowJohnny]

While I think the "who you know" notion in your post is true for surgical (and some non-surgical) paths, I have to believe that a program where you spent a month auditioning and actually know all the players is going to be more helpful than a big name person's letter. Most programs don't get very good look at applicants in the interview process. When they get a better look at someone through an away rotation, and actually like them, that has to help. And a PD's own perception of an applicant will usually outweigh some other program's perception. So I'd say if you do an away at a program you have a shot at, and they like you, the odds of them ranking you highly are maximized. A letter from another program's bigwig probably helps a bit at programs you don't get to audition at, but I think it's probably lower yield. But only a PD can tell us this for sure.

This is one of the rare opportunities I have to disagree with Law2Doc, but on a minor point. While this is good advice for the majority specialties, there's something weird about certain surgical subspecialties (Plastics and ENT spring to mind, according to my friends matching in them) where there is an assumption that if you do NOT rotate at a big academic institution and receive a letter from a bigwig, your application is considerably weakened versus someone who did.

It's a weird system, but basically, it's a very formalized "Boys club" system. You rotate at "Great Plastics Hospital", you maybe only work with Dr. Famous two or three times, but he (and other famous faculty) talk to all faculty and residents and decide who they want to write letters for.

Anyway, this is all second hand, but seeing what my buddies went though, I'd believe it.

However, take this with a couple of asterixes. First, you need to find out how it works for the field you're applying it, which you can best get info by tracking down people who applied in the past. Certain fields operate like this, some care more about research like derm and rad onc, radiology is all about numbers, etc. etc. If you do find out that you are thinking about a field where a rotation at a big academic place is required, my advice applies. If not, disregard.

Second, it IS a good suggestion to rotate at a place where you are a "competitive applicant" in these super competitive fields IN ADDITION to the top name places, so I don't think it's an either/or situation.

 

[Apply Pressure]

Are you going into surgery?

The "competitive" field I'm considering is non-surgical and not as competitive as derm

 

[Rogue Synapse]

The "competitive" field I'm considering is non-surgical and not as competitive as derm

Do you really like eyes? Give us a hint.

 

[dragonfly99]

It's probably rads.
Anyway, I think you should post a question in the forum(s) specifically related to your specialty of interest. You'll probably get the best advice there.

Perhaps the safest strategy would be:
1) rotate at "big whig hospital" in your specialty of choice, and try to get a LOR from there
AND
2) rotate at "not so bigwhig hospital" or your own institution in your specialty of choice, as an audition rotation and try REALLY hard to impress them
AND
3) apply to internal medicine (either prelim or categorical) as a backup, but NEVER use the word "backup" during your IM interviews, particularly if you are applying to categorical IM (LOL!)

Can you fit in a couple of research months during the first half of 4th year in your chosen field?

 

[txguy]

It's probably rads.
Anyway, I think you should post a question in the forum(s) specifically related to your specialty of interest. You'll probably get the best advice there.

Perhaps the safest strategy would be:
1) rotate at "big whig hospital" in your specialty of choice, and try to get a LOR from there
AND
2) rotate at "not so bigwhig hospital" or your own institution in your specialty of choice, as an audition rotation and try REALLY hard to impress them
AND
3) apply to internal medicine (either prelim or categorical) as a backup, but NEVER use the word "backup" during your IM interviews, particularly if you are applying to categorical IM (LOL!)

Can you fit in a couple of research months during the first half of 4th year in your chosen field?

I am pretty sure its Radiology as well. Besides the above advice, obviously try to honor as many of your remaining rotations as you can (especially medicine and surgery) and definitely take step 2 early and ROCK it. Radiology is known to heavily weigh the "numbers" on your application.

Good luck to you. Come on over to the Rads forum for some more advice and good luck!